Provider Demographics
NPI:1790018356
Name:BURGESS, TARA MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MICHELLE
Last Name:BURGESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:MA
Mailing Address - Zip Code:01867-1144
Mailing Address - Country:US
Mailing Address - Phone:603-969-4099
Mailing Address - Fax:
Practice Address - Street 1:333 LONGWOOD AVE # LO-367
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5711
Practice Address - Country:US
Practice Address - Phone:617-355-8859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-15
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA3819363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant